Patient Case Clerkship

PH210
PHARMACY CLERKSHIP
HOSPITAL PUTRAJAYA

Case 5
Congestive Cardiac Failure
Nephrotic Syndrome
Community-Acquired pneumonia

Siti Hasmah Bt Mohd Suffian
(2006200606)

CASE SUBJECT

Name: MAM Gender: Male
Age: 24 years old Race: Malay
Weight: 138 kg BMI: 55 (morbidly obese)
Height: 159cm DOA: 21st March 2010

SUBJECTIVE

Chief complaint:
• bilateral lower limb swelling for the past 2 weeks.
• scrotal swelling for the past 3 days but noted on DOA had progressively increased in size.
• complained of vomiting for 5 days, vomits about 3-4 times per day
• so far had vomited once in the afternoon and had 2 episodes of diarrhea on DOA

History of present illness:
• had noted excoriation of the scrotal skin with some amount of clear fluid discharge
• has been having difficulties in initiating micturation since morning of DOA
• claimed that bladder habits were normal before this
• history of occasional SOB for the past 2 weeks
• orthopnea for 2 weeks
• had reduced effort tolerance for the past 1 month
• diarrhea for the past 3 days
• has abdominal distension for the past 1 month
• associated with abdominal discomfort and occasional bouts of vomiting
• had seen the doctor and was treated for gastritis
• had one episode of fever last friday
• had epigastric pain since DOA
• loss of appetite for the past 1 month
• Had on and off cough for pass 2 months, whitish sputum

Family history:
• father passed away due to esophageal cancer
• mother has hypertension and diabetes mellitus

Social history:
• smoker for the past 8 years (14 sticks per day) but quitted 2 months ago

Past medical and medication history:
• Have been taking T. Piroxicam (Roxim) for his pain management
• History of peptic ulcer 3 months ago
OBJECTIVE

Review of system:
• BP = 127/54 mmHg
• PR = 115 bpm (regular good volume)
• T = 37oC
Lab values on day of admission:
Patient’s value Normal Values
Full blood count TWBC 25.6x 109/L 4-11 x... [continues]

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